1, the definition of hypertension: in the case of non-use of antihypertensive drugs, non-same day three measurements of blood pressure, systolic blood pressure ≥ 14O mm Hg and/or diastolic blood pressure ≥ 9O mm Hg. Patients with a history of hypertension, currently using antihypertensive drugs, although the blood pressure is lower than 140/9O mm Hg, also diagnosed as hypertension.
2. Prevalence: In the past 5O years, the prevalence of hypertension in our population has been on the rise. According to the number and structure of the population, there are about 200 million hypertensive patients in China, and 2 out of every 1O adults suffer from hypertension. The prevalence of hypertension in China’s population is characterized by an increasing prevalence of hypertension from the south to the north, with some differences in the prevalence of hypertension among different ethnic groups. High sodium and low potassium diets are one of the main risk factors for the development of hypertension in most of the patients in China. Overweight and obesity are another important risk factor for the increasing prevalence of hypertension in China. The overall awareness, treatment and control rates of hypertension patients in China are low, below 5O%, 4O% and 1O%.
3, hypertension risk: regardless of the measurement method used including office blood pressure, ambulatory blood pressure or home blood pressure, blood pressure levels were continuously, independently and directly positively correlated with the risk of stroke and coronary heart disease events. Systolic blood pressure is more strongly associated with cardiovascular risk than diastolic blood pressure. Currently, coronary events are rapidly increasing, but stroke is still the most significant complication in our hypertensive population.
4. Medical history and signs.
(1) Family history: Family history of hypertension, diabetes, dyslipidemia, coronary heart disease, stroke or kidney disease.
(2) Duration of disease: the time of hypertension, the highest level of blood pressure, whether they have received antihypertensive treatment and its efficacy, and adverse effects.
(3) Symptoms and past history: presence and treatment of coronary heart disease, heart failure, cerebrovascular disease, peripheral vascular disease, diabetes mellitus, gout, dyslipidemia, bronchial asthma, sleep apnea syndrome, sexual function abnormalities and renal disease.
(4) The presence of secondary hypertensive symptoms, such as a history of nephritis or anemia, hypokalemic manifestations such as muscle weakness and episodic flaccidity, paroxysmal headache, palpitations, and excessive sweating.
(5) Lifestyle: dietary fat, salt and alcohol intake, number of cigarettes smoked, physical activity and weight change, etc.
(6) Drug-induced hypertension: whether or not to take drugs that increase blood pressure, such as oral contraceptives, gastrosterone, nasal drops, cocaine, amphetamines, steroids, non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine and traditional Chinese medicine licorice, etc.
(7) Psychosocial factors: family situation, work environment, education level and history of trauma in Packard.
Blood pressure measurement: Blood pressure measurement is the main means to assess blood pressure level, diagnose hypertension and observe the efficacy of antihypertensive therapy. The three main methods used in clinical and population control work are office blood pressure, ambulatory blood pressure, and home blood pressure. In-office blood pressure is still a common method for clinical diagnosis and classification of hypertension. Ambulatory blood pressure monitoring is used not only for the diagnostic evaluation of hypertension, but also to diagnose white coat hypertension, detect occult hypertension, examine the causes of intractable hypertension, and assess the degree of blood pressure elevation, short term variability, and circadian rhythm. Home blood pressure monitoring not only measures long-term blood pressure variability, but also avoids the white coat effect and provides insight into the patient’s blood pressure in the normal course of life, improving adherence to treatment.
Physical examination: blood pressure and heart rate, blood pressure in the prone position and extremities if necessary, measurement of body mass index (BMI), waist circumference and hip circumference, observation of Cushing’s face, hyperthyroidism or lower limb edema, palpation of the thyroid gland, auscultation of murmurs in the carotid, thoracic aorta, abdominal and femoral arteries, cardiopulmonary signs, abdominal masses or renal enlargement (polycystic kidney), arterial pulsations in the extremities, etc. neurological signs, etc.
Laboratory tests.
1. Basic items: blood biochemistry (potassium, glucose, total serum cholesterol, LDL cholesterol, triglycerides, HDL cholesterol, uric acid, creatinine), complete blood count, hemoglobin and hematocrit, urinalysis (urine protein, sugar and sediment microscopy), electrocardiogram.
2.Recommended items: 24h ambulatory blood pressure monitoring, echocardiography, carotid ultrasound, postprandial glucose, homocysteine, urine albumin quantification, urine protein quantification, fundus, chest radiograph, pulse wave conduction velocity, and ankle-arm blood pressure index.
3. Selected items: plasma renin activity, blood and urine aldosterone, blood and urine cortisol, blood free methoxyprenaline (MN) and methoxynorepinephrine (NMN), blood and urine catecholamines, renal and adrenal ultrasound, CT or MRI, sleep apnea monitoring, arteriography, etc. For hypertensive patients with comorbidities, appropriate functional examinations of the heart, brain, kidney and other target organs are performed.
Classification and stratification of hypertension diagnosis
Diagnostic assessment includes the following three aspects.
(1) Determining the classification of hypertension by blood pressure level.
(2) Finding other cardiovascular risk factors, target organ (heart, brain, kidney, blood vessels, fundus, etc.) damage, and related clinical conditions for risk stratification.
(3) Determine the cause of hypertension and clarify the presence or absence of secondary hypertension.
Classification by blood pressure level: Hypertension is defined as systolic blood pressure ≥ 14OmmH/g or/and diastolic blood pressure ≥ 9OmmH g without the use of antihypertensive drugs. Hypertension is further classified into grade 1, grade 2 and grade 3 according to the level of elevated blood pressure. Generally, 2-3 non-same-day measurements are required to determine elevated blood pressure and its classification, especially for mild and moderate elevations.
Cardiovascular risk factors: hypertension (grades 1 to 3); men >55 years and women >65 years; smoking; impaired glucose tolerance (2-hour glucose 7.8-11.O mmol/L) and/or abnormal fasting glucose (6.1-6.9 mmol/L); dyslipidemia with TC ≥5.7 mmol/L (22Omg/dL) or LDL-C >3.3 mmol/L ( 13Omg/L) or HDL-C<1.Ommol/L (4Omg/dL); family history of early-onset cardiovascular disease (age of onset in first-degree relatives <5O years); abdominal obesity (waist circumference: men ≥9Ocm, women ≥85cm), or obesity (BMI ≥28kg/m2); high blood homocysteine (≥1Ou mol/L).
Target organ damage (TOD): left ventricular hypertrophy, ECG SokoIow-Lyons>38mv or Cornell>244Omm*mms, echocardiographic LVMI ≥125 g/m2 in men and ≥12Og/m2 in women; carotid ultrasound IMT ≥O.9mm or atheromatous plaque; carotid-femoral pulse wave velocity ≥12m/s; ankle/arm Blood pressure index
Differential diagnosis
See Diagnostic points of secondary hypertension for details
Treatment plan and principles
1.Treatment goal: In patients with detected hypertension, use appropriate anti-hypertensive drugs on the basis of non-pharmacological treatment, especially drugs that can control blood pressure for 24h once a day, as well as control other reversible risk factors and effectively intervene in detected subclinical target organ damage and clinical disease.
2, the goal of blood pressure lowering: gradually lowering the blood pressure to the target as the patient can tolerate. In general hypertensive patients, blood pressure (systolic/diastolic) should be reduced to less than 14O/9OmmHg; in elderly people over 65 years old, systolic blood pressure should be controlled to less than 15OmmHg, and can be further reduced if tolerated; hypertensive patients with renal disease, diabetes or stable coronary artery disease should be treated more individually, and blood pressure can generally be reduced to less than 13O/8OmmHg . Patients with coronary artery disease or stroke in the acute phase should have their blood pressure managed according to the relevant guidelines.
3. Treatment strategy: Assess the overall risk of the patient comprehensively and make treatment decisions based on risk stratification. For very high-risk and high-risk patients, immediately start comprehensive treatment for hypertension and coexisting risk factors and clinical conditions; for intermediate-risk patients, observe the patient’s blood pressure and other risk factors for several weeks to assess target organ damage, then decide if and when to start drug therapy; for low-risk patients, observe the patient for a longer period of time and measure blood pressure repeatedly, then decide if and when to start Low-risk patients, patients are observed for a longer period of time, blood pressure is measured repeatedly, and then a decision is made whether and when to start drug therapy.
4, comprehensive treatment: hypertension is a “cardiovascular syndrome”, should be based on the overall cardiovascular risk, determine the treatment measures. Comprehensive intervention of multiple risk factors, active lipid regulation, blood glucose control, antiplatelet therapy, and active anticoagulation if complicated by atrial fibrillation. Hypertension is a “lifestyle disease”, seriously change the poor lifestyle, reduce sodium intake, increase potassium intake, control weight, do not smoke, do not drink alcohol in excess, physical activity, reduce mental stress, maintain psychological balance. Pay attention to children and adolescents with hypertension and shift the prevention gate forward. Pay attention to the screening and treatment of secondary hypertension. Strengthen community prevention and treatment of hypertension, regular blood pressure measurement, standardized management, rational use of drugs, and improve the awareness rate, treatment rate and control rate of hypertension in our population.
The basic principles of antihypertensive drugs: start with small doses, give preference to long-acting agents, combine applications, and individualize.
Commonly used antihypertensive drugs: including calcium antagonists (CCB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), diuretics and beta-blockers, as well as fixed-ratio compound preparations composed of the above drugs. In addition, alpha-blockers or other types of antihypertensive drugs can sometimes be used in certain hypertensive populations.
1, diuretics: sodium drainage, lowering the volume load to lower blood pressure. Hydrochlorothiazide and indapamide are commonly used in China. Especially suitable for elderly hypertension, systolic hypertension alone or with heart failure patients, is the basic drug for refractory hypertension. Thiazide diuretics can cause hypokalemia, which is prohibited in gout, and used with caution in hyperuricemia and renal insufficiency, the latter if you need to use diuretics, choose tab diuretics. Potassium-preserving diuretics such as amiloride and aldosterone receptor antagonist spironolactone can also be used to control blood pressure, pay attention to hyperkalemia, spironolactone long-term application may lead to gynecomastia.
2, CCB: blocking calcium channels in vascular smooth muscle cells to dilate blood vessels and lower blood pressure. Dihydropyridine CCB can be used in combination with other commonly used 4 drugs. Common adverse reactions include reflex sympathetic activation leading to rapid heartbeat, facial flushing, ankle edema, gingival hyperplasia, etc. Non-dihydropyridine CCB can also be used for antihypertensive treatment. Common adverse effects include inhibition of cardiac systolic function and conduction function, and sometimes gingival hyperplasia.
3, ACEI: inhibit angiotensin converting enzyme, blocking the renin angiotensin system to play an antihypertensive effect, no adverse effects on glucose and lipid metabolism. It is especially suitable for patients with chronic heart failure, post-myocardial infarction with cardiac insufficiency, diabetic nephropathy, non-diabetic nephropathy, metabolic syndrome, proteinuria or microalbuminuria. The most common adverse reaction is persistent dry cough. Other adverse reactions include hypotension, rash, and occasionally angioneurotic edema and taste disturbance. Monitor blood potassium and creatinine levels regularly. Contraindications are bilateral renal artery stenosis, hyperkalemia and pregnancy.
4.ARB ：Block angiotensin type I receptors to exert antihypertensive effect. It is especially suitable for patients with left ventricular hypertrophy, heart failure, atrial fibrillation prevention, diabetic nephropathy, metabolic syndrome, microalbuminuria or proteinuria, and patients who cannot tolerate ACEI. Adverse effects are rare, with occasional diarrhea, and monitoring of changes in blood potassium and creatinine levels. Bilateral renal artery stenosis, pregnant women, and hyperkalemia are contraindicated.
5, β-blockers: inhibit the over-activated sympathetic nerve activity, inhibit myocardial contractility, slow down the heart rate to achieve antihypertensive effect. Highly selective β1 receptor blocker, light effect on β2 receptors, less adverse effects, can reduce blood pressure, but also protect target organs, reduce the risk of cardiovascular events. β receptor blockers are particularly suitable for patients with tachyarrhythmia, coronary angina, chronic heart failure, increased sympathetic activity and hypertension in the hyperdynamic state. Common adverse effects include fatigue, cold sensation in the limbs, agitation, gastrointestinal discomfort, etc. It may also affect glucose and lipid metabolism. Patients with high degree of heart block and asthma are contraindications. Use with caution in patients with chronic obstructive pulmonary disease, athletes, peripheral vascular disease, or abnormal glucose tolerance. Sudden discontinuation of long-term application may cause rebound phenomenon.
6, alpha-blockers: not as the first choice of general hypertension treatment, for hypertension with prostatic hyperplasia patients, also used for refractory hypertension patients, the start of medication should be before going to sleep to prevent postural hypotension, the use of attention to the measurement of blood pressure in the sitting position, preferably using controlled-release preparations. It is contraindicated in patients with postural hypotension. Heart failure is used with caution.
7, renin inhibitors: a new class of antihypertensive drugs, can significantly reduce the blood pressure level of hypertensive patients, but the impact on cardiovascular and cerebrovascular events has yet to be evaluated in large-scale clinical trials.
Combined application of antihypertensive drugs: The main recommended application and optimal combined treatment plan in China is: dihydropyridine CCB plus ARB, dihydropyridine CCB plus ACEI, dihydropyridine CCB plus zithromax diuretics, dihydropyridine CCB plus beta-blockers, ARB plus thiazide diuretics, ACEI plus thiazide diuretics. The secondary recommended and acceptable combination regimens are: diuretics plus beta-blockers, alpha-blockers plus beta-blockers, dihydropyridine CCB plus potassium-protective diuretics, and thiazide diuretics plus potassium-protective diuretics. Combination regimens that are not routinely recommended but can be used with caution when necessary are: ACEI plus beta-blocker, ARB plus beta-blocker, ACEI plus ARB, centrally acting drugs plus beta-blocker. The combination of multiple drugs: three-drug regimen, in which another antihypertensive drug is added to the above two-drug combination, constitutes a three-drug combination regimen, among which the combination of dihydropyridine CCB + ACEI (or ARB) + thiazide diuretics is the most commonly used; the four-drug combination regimen, mainly for patients with refractory hypertension, can be added to the above three-drug combination with a fourth drug such as β receptor blocker, spironolactone, colistin or α-blocker, etc.